Samaritan Nursing and Rehab, West Bend, Wisconsin
- 65
- Citations from health inspectionsWisconsin average: 28 a home
- 4
- Residents harmed or put in dangerWisconsin average: 2.0 a home
- $236,983
- Fines from the federal governmentWisconsin average: $48,150 a home
- 1 out of 5
- Overall rating in starsWisconsin average: 3.0
The figures come from Medicare Care Compare files released October 8, 2026 by CMS, the federal Medicare agency. The citations span each home's three most recent inspection cycles plus their complaint visits, going back to March 2017 at the earliest; the fines span about three years, beginning September 2023. Browse the CMS files
12 inspection visits produced 65 citations. Residents were in immediate danger in four findings. Federal fines came to $236,983 (three fines). Once, Medicare stopped paying for new admissions.
The CMS abuse icon is shown for this home. Care Compare adds it after a citation for abuse or neglect. Either a resident was harmed recently, or harm could have resulted over two inspections in a row.
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- The home's overall star rating
- 1 out of 5
- Rating for health inspections
- 1 out of 5
- Rating for staffing
- 4 out of 5
- Rating for quality of care
- 3 out of 5
- Nurse time for each resident
- 4.95 hours each dayThe Wisconsin average is 4.21 hours
- Time from registered nurses
- 1.28 hours each dayThe Wisconsin average is 0.99 hours
- Nursing staff who left during one year
- 75.7%against the Wisconsin average of 46.9%
- Beds that are certified
- 131
- Ownership
- Limited Liability company (for profit)
- Chain
- Shlomo Hoffman, with 10 homes
- Street address
- 531 E Washington St, West Bend, Wisconsin 53095
- County
- Washington
Each inspection's citations
Every citation marks a federal rule inspectors found broken, along with its seriousness and the number of residents affected.
14 citations dated May 18, 2026
- F887 Coronavirus Vaccine Education, Offering, and Records: risk of harm, no one found hurt, one or a few residents.
- F883 Flu and Pneumonia Vaccines: risk of harm, no one found hurt, one or a few residents.
- F881 Antibiotic Use Monitoring Program: risk of harm, no one found hurt, one or a few residents.
- F880 Infection Prevention and Control: risk of harm, no one found hurt, widespread.
- F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, widespread.
- F804 Food Taste and Temperature: risk of harm, no one found hurt, one or a few residents.
- F761 Labeling and Locking Up Medicines: risk of harm, no one found hurt, a pattern, several residents.
- F755 Pharmacy Services: risk of harm, no one found hurt, one or a few residents.
- F732 Post Daily Nurse Staffing Information: minimal risk to residents, widespread.
- F726 Nurses and Aides Have Needed Skills: risk of harm, no one found hurt, one or a few residents.
- F690 Bladder, Bowel and Catheter Care: risk of harm, no one found hurt, one or a few residents.
- F689 Accident Hazards and Supervision: risk of harm, no one found hurt, one or a few residents.
- F657 Updating the Care Plan on Time: risk of harm, no one found hurt, one or a few residents.
- F607 Policies to Prevent Abuse, Neglect, and Theft: risk of harm, no one found hurt, one or a few residents.
12 citations dated April 20, 2026
- F947 Nurse Aide Skills, Dementia, and Abuse Training: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F850 Full Time Social Worker in Large Facilities: risk of harm, no one found hurt, widespread, found on a complaint visit.
- F803 Menus That Meet Nutrition Needs: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F760 Significant Medication Errors: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F759 Medication Error Rate of 5 Percent or More: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F689 Accident Hazards and Supervision: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F684 Quality of Care: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F677 Help With Daily Living: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F610 Investigating Abuse Allegations: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
- F609 Reporting Suspected Abuse: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
- F607 Policies to Prevent Abuse, Neglect, and Theft: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F600 Freedom From Abuse and Neglect: immediate danger to residents, one or a few residents, found on a complaint visit.
One citation dated March 11, 2026
- F804 Food Taste and Temperature: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
Four citations dated Nov. 11, 2025
- F760 Significant Medication Errors: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F689 Accident Hazards and Supervision: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F686 Pressure Ulcer (Bedsore) Care: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F684 Quality of Care: immediate danger to residents, one or a few residents, found on a complaint visit.
Six citations dated Oct. 16, 2025
- F755 Pharmacy Services: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F695 Breathing and Oxygen Care: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F689 Accident Hazards and Supervision: immediate danger to residents, one or a few residents, found on a complaint visit.
- F684 Quality of Care: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F610 Investigating Abuse Allegations: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F609 Reporting Suspected Abuse: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
Three citations dated Aug. 26, 2025
- F804 Food Taste and Temperature: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
- F761 Labeling and Locking Up Medicines: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
- F755 Pharmacy Services: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
Two citations dated July 29, 2025
Three citations dated April 23, 2025
- F806 Food That Meets Allergies and Preferences: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F755 Pharmacy Services: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F697 Pain Management: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
11 citations dated Jan. 29, 2025
- F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, widespread.
- F803 Menus That Meet Nutrition Needs: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
- F770 Timely Quality Laboratory Services: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F755 Pharmacy Services: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F690 Bladder, Bowel and Catheter Care: risk of harm, no one found hurt, one or a few residents.
- F686 Pressure Ulcer (Bedsore) Care: risk of harm, no one found hurt, one or a few residents.
- F585 Right to File Complaints Without Retaliation: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F584 A Safe, Clean, Homelike Room: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F583 Keep Resident Records Private: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F582 Notice of Medicare and Medicaid Coverage and Costs: risk of harm, no one found hurt, one or a few residents.
- F551 Representative May Exercise Resident Rights: risk of harm, no one found hurt, one or a few residents.
Two citations dated Dec. 5, 2024
- F803 Menus That Meet Nutrition Needs: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F755 Pharmacy Services: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
One citation dated Oct. 16, 2024
- F600 Freedom From Abuse and Neglect: immediate danger to residents, one or a few residents, found on a complaint visit.
Six citations dated Nov. 2, 2023
- F880 Infection Prevention and Control: risk of harm, no one found hurt, widespread, found on a complaint visit.
- F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, widespread, found on a complaint visit.
- F692 Enough Food and Fluids: risk of harm, no one found hurt, one or a few residents.
- F686 Pressure Ulcer (Bedsore) Care: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F684 Quality of Care: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F610 Investigating Abuse Allegations: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
Payment Denials and Fines
| Date | Penalty | Amount |
|---|---|---|
| Nov. 11, 2025 | Fine | $26,685 |
| Nov. 11, 2025 | Payment denial for new admissions | seven days |
| Oct. 16, 2025 | Fine | $134,800 |
| Oct. 16, 2024 | Fine | $75,498 |
Ownership and Management of the Home
Two people with an ownership stake are also listed by CMS.
The CMS Care Compare files, updated every month, provide provider information, health deficiencies, penalties, and ownership. The CMS certification number is 525165. Other homes in Wisconsin.